Provider Demographics
NPI:1831270420
Name:POTTER, SUSAN MARY (FNP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARY
Last Name:POTTER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:MARY
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:7500 RIALTO BLVD STE 1-140
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78735-8534
Mailing Address - Country:US
Mailing Address - Phone:512-730-3056
Mailing Address - Fax:888-730-1925
Practice Address - Street 1:500 N HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75092-7354
Practice Address - Country:US
Practice Address - Phone:512-730-3056
Practice Address - Fax:888-730-1925
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX520140207P00000X, 363L00000X
TXAP106025363LF0000X
TNAP106025363LG0600X
OK205349363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8N9964OtherBLUE CROSS & BLUE SHIELD
TXS47304Medicare UPIN
TX8G4478Medicare ID - Type Unspecified